School of Urban and Regional Planning

University of the Philippines

E. Jacinto St., Diliman, Quezon City 1101 PHILIPPINES

APPLICATION FOR ADMISSION PASSPORT SIZE

PHOTO
Please check (/) one:  Diploma in Urban and Regional Planning WITH NAME TAG
(Family Name,
 Master of Arts (Urban and Regional Planning)
✔ First Name and
 Doctor of Philosophy (Urban and Regional
Middle Initial)
Planning)

No. ___________
(Do not fill)

1. Name (Please print or use block letters):

RIVERA MARCK JOHN DIAZ

Family Name First Name Middle Name Maiden Name (If Married)

A. PERSONAL DATA

2. Date of Birth 3. Place of Birth 4. Citizenship 5. Country of Origin

JULY 27, 1995 PASAY CITY FILIPINO PHILIPPINES

6. Civil Status 7. Gender 8. Age 9. Religion

SINGLE MALE 23 ROMAN CATHOLIC

10. Present Home Address 11. Tel. No. / E-mail

118 SNT. ISABEL ST. MARICABAN, PASAY CITY 09367730121/
marckjohnriver
12. Provincial Home Address and Region a@gmail.com
13. Tel. No. / E-mail
None 09367730121/
marckjohnriver
a@gmail.com
Professional Regulation Commission (PRC) Examination
Title of the Examination Date Taken Ranking PRC License No.

GEODETIC ENGINEER BOARD EXAM OCTOBER 2017 0010078

B. WORK EXPERIENCE

14. Name of Office and Address 15. Tel No. / E-mail

DEPARTMENT OF TRANSPORTATION / CLARK, PAMPANGA

16. Department 17. Designation 18. Salary  Government

19. Nature of Office ✔
PROJECT
OFFICE OF THE UNDERSECRETARY DEVELOPMENT OFFICER PHP 30,000
FOR RAILWAYS - GEODETIC ENGINEER
 Private  Others ________
20. Nature of Work (Describe briefly)

21. Describe extensively planning or planning-related experience in the last ten years (Name of Office, Position/Designation,
No. of employees under you, etc.) use separate sheet if necessary:

22. Name other offices where you worked in the last ten (10) years, if any:

Position Name of Office Nature of Work Years

GEODETIC ENGINEER JMP BERNABE

C. ACADEMIC / TRAINING BACKGROUND

23. Diploma / Degree Obtained

Title of Diploma / Date Received Institution/Address Honors
Degree Obtained Received
Secondary
DIPLOMA
Collegiate

Graduate

24. Fellowship Awards (State nature, awarding institution, date and place of award)

25. Training Programs attended (Only in the last 5 years):

26. Title of Undergraduate Thesis 27. Title of Postgraduate Thesis

28. Publication/s (In the last 10 years)

D. PROPOSED PLAN OF STUDY

29. Describe briefly the relevance of DP / M.A. / Ph.D. program to your career plans and objectives.

30. Program Option  Full-time (For M.A. applicants only)  M.A. Thesis

 Part-time  M.A. Non-Thesis

31. Financial Support :  Self Supporting  Parents

 Agency Scholar  Others (Specify) ________________________

E. REFERENCES

32. List the names, positions, offices and addresses of two or more persons whom you asked to fill up the attached reference forms.

Name Position Office and Address

Have you ever been convicted of any crime or violation of any law, decree, ordinance, or regulation by any court or tribunal?
 YES  NO

I hereby affirm that all information supplied herein is complete and accurate. Withholding or giving false information will
make me ineligible for admission or subject to dismissal. If admitted, I agree to abide by the policies, rules and regulations
of the University of the Philippine.

Signature: _____________________________________ Date: ____________________________

(Do Not Fill)

U.P. OR No.: ______________________ Date of Payment: ____________________

Document/s Submitted:

_____ Original/Photocopy Transcript of Records _____ Original/Photocopy Marriage Contract

_____ Undergraduate _____ Four (4) photos

_____ Graduate _____ References

_____ Original/Photocopy Birth Certificate